It Takes a Village. ABA, SLP and OT: Bridging the Gap to Enhance Services for Children with ASD. Thank You to My Co-Collaborator on this Work

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1 ABA, SLP and OT: Bridging the Gap to Enhance Services for Children with ASD Thank You to My Co-Collaborator on this Work Mareile Koenig, Ph.D., CCC-SLP, BCBA West Chester University, PA Joanne Gerenser, Ph.D. It Takes a Village Children with ASD have a spectrum of needs, and it takes a professional village to address these needs COLLABORATION AND SHARED PRACTICE 4 1

2 It Takes a Village, cont. SLP, OT & ABA professionals are important members of that village 5 Each brings valuable contributions to the table!technically, the expertise of each profession actually complements the other Working Together What can happen when professionals work together? 6 Collaboration Shared Practice Encroachment Working Together, cont. Collaboration occurs when professionals 7 from different disciplines work together to support a client in complementary performance domains e.g., SLP communication OT fine motor skills ABA socially-appropriate behavior Working Together, cont. Shared Practice is a special case of collaboration that occurs when professionals from different disciplines support a client s needs within overlapping performance domains -e.g., SLP speech-language-communication needs OT social communication needs ABA verbal behavior & functional comm. skills 8 2

3 Working Together, cont. Encroachment is a negative term referring to shared practice involving service providers who step outside of their scope of practice 9 e.g., see ASHA (2011) This is a risk factor in shared practice Interestingly, we hear more about this in SLP-ABA collaboration than in SLP-OT collaboration Working Together, cont. Our goals in advocating for SLP-ABA -OT Collaboration are 1. To encourage collaboration & shared practice 2. To avoid encroachment 10 Models of Collaboration Most of us learn about 3 models of collaboration Multidisciplinary Interdisciplinary Transdisciplinary Multidisciplinary Model Multiple Professionals Independent Appointments Independent Reports Indep. Recs

4 Interdisciplinary Model Transdisciplinary Model Family members are team members Team members collect & review data together Results represent integration & consensus of all Challenges of the Transdisciplinary Model Scheduling Role Release & Role Sharing Role Release & Role Sharing Important for all team functions Assessment ID & prioritization of learning objectives Intervention planning and delivery Communication with families

5 Role Release & Role Sharing, cont. Requires openness to 17 Teaching other team members what we do Learning what others do Providing constructive feedback Receiving constructive feedback Recognize & utilizing overlap between roles Advantages to Collaboration, cont. It s a win-win-win 18 Professionals can learn from each other Families can be spared some confusion Ultimately, children will receive the best possible support The biggest challenges for children are: Communication Social skills Behavioral challenges ISSUES THAT INFLUENCE OT-SLP-ABA COLLABORATION 5

6 A Short List of Issues 1. Overlapping scopes of practice 2. Overlapping competencies 1. Overlapping Scopes of Practice Scope of Practice description of the kinds of problems addressed by a profession. 3. Different frameworks for solving similar clinical problems Ethical standards require professionals to limit their service delivery to problems within their professions scope of practice Baggage: misconceptions about the other profession s skill set 22 Overlapping Scopes of Practice, cont. Support the needs of individuals with a wide range of disorders of communication, speech, language, literacy, and swallowing SLP Support communication impairments including the reduction of problem behaviors that stem from inadequate communication skills ABA Support a wide range of problems that challenge individuals and organizations in the performance of socially-valued verbal and nonverbal behaviors. Overlapping Scopes of Practice, cont. Consider the biggest challenges for young children with ASD Communication Social skills Maladaptive Behavior 23 ASHA BACB The Scopes of Practice for SLP and ABA professionals each target these skills 24 6

7 Overlapping Scopes of Practice, cont. All professionals target communication but the focus may be different 25 SLPs see communication as an end goal BAs see this as a preventive measure i.e., learning adaptive communication skills negates the need for maladaptive behavior OTs may focus more on contextual and family role 2. Overlapping Competencies Competencies the professional knowledge and skills needed to engage in a scope of practice 26 Interesting note: an person s competencies may not cover the entire Scope of Practice Ethical standards and EBP require us to use only those strategies for which we have the competency SLP Competencies knowledge and skills related to areas that impact the development of communication 27 Anatomy and physiology of the speech, language & hearing mechanisms Components of language and methods of linguistic analysis Developmental sequences and natural environmental conditions that support them (SLPs, cont.) 28 Developmental risk and of abnormal developmental processes Options for AAC systems Methods for assessing a child s communication profile Procedures for teaching communication skills (adult-directed, child-directed, hybrid) 7

8 BCBAs competencies knowledge and skills that impact the instructional design, implementation, and assessment. e.g., 29 Fundamental elements of behavior change: shaping, prompting, and chaining Specific behavior-change procedures and systems: differential reinforcement and extinction Task analysis (BCBA, cont.) Individualized reinforcement systems Positive behavior support (PBS) strategies Analysis of controlling variables (ABC) Analysis of Verbal Behavior (AVB) Errorless teaching strategies 30 Daw, Holman, & Heilicser (2014) studied the self-reported competencies of SLPs and BCBAs (Daw et al., 2014, cont.) Competencies with the most overlap: Participants: 19 SLPs & 16 BCBAs In a survey, each was asked to assessed his/her own competencies in relation to 23 skills considered important for autism service delivery Results!

9 (Daw et al., 2014, cont.) Competencies with the least overlap 33 SLPs reported greater levels Competences that ranged between most and least overlap: Expressive Language Early Childhood Lang Receptive Language AAC Motor Planning Social Pragmatics Choosing Verbal Behavior Reinforcement Errorless learning Prompt Fading Shaping 34 BCBAs reported greater levels However, please note: SLPs are not brain surgeons! Our competencies include much knowledge in related areas But intervention is a behavioral process This is one of the paradoxes of our profession (Hegde, ) Most of the interventions used by SLPs have their origin in ABA e.g., drill reinforcement drill play shaping prompting chaining We use the strategies but we ve become disconnected from the science that brought these strategies to the table. 36 (Koenig & Gerenser, 2006) 9

10 Using a strategy w/o understanding the science is not the same as competence in ABA. Behavior analysts sometimes cringe when someone not well-versed in ABA says, I do ABA The good news We can become reconnected When the connection is strong, wonderful things can and do happen e.g.,! Robert & Lynn Koegel Lori Frost & Andy Bondy

11 And many others as well 3. Different Frameworks!Different frameworks can lead to problems when team members do not understand important features of each other s mode of operation: "Priorities "Strategies 41 "Terminology 42 Different Frameworks, cont. e.g., Differences in the prioritization of targets SLP Tend to Descriptive Communication Profiling (assess speech, language, and collateral areas) Developmental linguistic framework for target selection Emphasis on naturalistic contexts for treatment. Tend to ABA Functional Behavior Assessment Task analysis Criterion-referenced testing Think outside of the developmental box (C w/ ASD may learn differently) Different Frameworks, cont. e.g., Differences in teaching methodologies SLP Emphasis on evidencebased eclecticism Adult-Directed Child-Directed Hybrid ABA Emphasis on procedures based on learning theory Antecedent Behavior Consequence 44 11

12 Different Frameworks, cont. e.g., Differences in technical terms Different Frameworks, cont. SLP Terms 1. Communicative Temptations 2. Imitation 3. Requesting 4. Naming 5. Conv. turn-taking 6. Carry-over 45 ABA Terms 1. Establishing Operations 2. Echoic 3. Manding 4. Tacting 5. Intraverbal 6. Generalization But, are we REALLY so different? SLP intervention strategies are behavioral. Aren t the differences complementary? SLPs are experts in what to teach BCBAs are experts behavioral teaching 46 Different Frameworks, cont. Train metaphor For children with ASD, SLPs can be experts about what goes in the train 47 BCBAs can be experts in how to drive it 3. Baggage Misconceptions and stereotypes, often born of insufficient information Stereotypes about ABAs! They teach children to perform like robots! They use bribery! They are obsessed about data collection! They know nothing about 48developmental processes Stereotypes about SLPs! They only do play therapy.! They don t collect data.! They only do pullout therapy! Their methods aren t sciencebased 12

13 3. Baggage Misconceptions and Stereotypes of OTs Just focus on sensory integration Don t take any data Only works on fine motor skills Methods are not science based Baggage, con. Who are THEY? The worst examples of each profession? No profession is perfect The worst example does not define the group More about baggage, later. Reality Check How do SLP and ABA professionals perceive the collaborative process? We conducted an exploratory pilot study Surveys Surveys were sent to All 319 members of SLP-ABA discussion group Members include SLP & ABA professionals Mostly U.S. Some Canadian Directors of 15 programs for ASD in U.S. Directors disseminated to SLP & ABA staff We estimate a total of 425 invitations 143 surveys were returned Response rate about 33.4 % 13

14 3 Types of Respondents The group is skewed towards easterners N = 114 (64 SLPs + 50 BAs) Number of Respondents % of respondents Geographical Regions We targeted only SLPs and BAs who serve children with autism 92% provide direct service 8% supervise direct service providers # of Different Universities Participants were educated at different universities across the country For SLP Groups of Respondents For ABA 14

15 One of our questions pertained to challenges in collaboration What (if anything) do you find challenging about collaborating with [ABA, SLP] professionals? Responses were open-ended Some respondents listed more than one issue A pattern analysis was conducted to categorize & summarize the responses Resulting categories of responses None = no challenges with collaboration Def = deficiencies in the other professional s knowledge base NegA = the other professional has a negative attitude about my profession Diff = we have a different theoretical framework; different mode of operation Adm = problems with collaboration are administrative MisU = our profession is misunderstood or underappreciated Lack K = I lack knowledge about the other profession % of responses in this category Perception of Collaboration Challenges None = no problems with collaboration Def = deficiency in other group NegA = other group has negative attitude Diff = we do things differently Admin = the barriers are administrative MsU = our group is misunderstood Lack K = I lack knowledge about the other group s content area These are provisional results that need to be confirmed Provisionally, they are consistent with our own experiences 15

16 Categories We also asked: What (if anything) do you find rewarding about collaborating with [ABA, SLP] professionals? Open-ended responses were invited Some respondents listed more than one issue Pattern analysis resulted in categories! None nothing rewarding about collaboration OL opportunity to learn about aspects of other field Exp appreciation for expertise of other professional CP appreciation of the collaborative process DP opportunity to learn about different perspective SP collaborative process leads to student progress Misc. comments that didn t fit the above Their methods are the same as mine They support the need to measure & collect data Perception of Collaboration Rewards Consequences of Challenges % of responses in this category None = no rewards Learn Opp = It s an opportunity to learn from the other professional App Exprt = I appreciate the knowledge and skills of the other professional Collab Proc = I am rewarded by the collaboration process itself Progress = I appreciate the progress children make when collaboration works Diff Persp = Collaborating with the other professional illustrates a different perspective Misc = miscellaneous comments Confusion for Parents and other consumers Less than optimal service delivery 16

17 Improved Communication Possible Solutions SLPs and OTs will need to understand and respect the ABA framework ABA professionals will need to understand and respect the DSP approach We need to Learn each other s lang. about shared topics Work out the details of role sharing Consider this 8 Step Program Acknowledge the Problem 2. Understand each other s scope of practice 3. Acknowledge each other s strengths/limitations 4. Leave baggage at the door 5. Complement and Collaborate Step 1: Acknowledge the Problem Done! We ve got a problem 6. Engage in Life-Long Learning 7. Participate in National Advocacy 8. Advocate for Families 17

18 Step 2 Recognize each other s Scopes of Practice and understand the differences in theoretical frameworks Support the needs of individuals with a wide range of disorders of communication, speech, language, literacy, and swallowing Address communication impairments including the reduction of problem behaviors that stem from inadequate communication skills Support a wide range of problems that challenge individuals and organizations in the performance of socially-valued verbal and nonverbal behaviors. SLP Linguistic developmental framework Emphasis on form, content, use ABA Behavioral developmental framework Emphasis on operant learning: A!B!C ASHA BACB Step 3: Acknowledge Each Other s Strengths & Limitations in Autism Treatment Strengths of SLPs We understand normal communication processes We know about multiple ways in which these processes can be impaired Step 2, continued We understand the anatomy & physiology of speech production We understand the challenges of motor speech disorders Apraxia Dysarthria 18

19 We recognize a broad range of AAC options We understand the components of language Step 2, continued We re informed by developmental research Cognition Language Social Communication Step 2, continued We know how to use naturalistic treatment to promote generalization 19

20 Step 2, continued Leaders in our profession have provided many valuable resources for supporting children with autism Amy Wetherby! Lori Frost Barry Prizant! Carol Westby Lynn Koegel! M.N. Hegde Joe Reichle! Michelle Garcia Winner Rhea Paul! Patricia Prelock Sylvia Diehl! Rebecca Landa Kathleen Quill! Linda Hodgdon Kathy Dyer!Tamara Kasper Barbara Esch! Nancy Kaufman AND MANY OTHERS!! Step 2, continued Relative Limitations Less emphasis on autism-specific content in the graduate curriculum KASA standards do emphasize socialcommunication There s less emphasis on autism-specific issues " Things have improved in the past 10 yrs, but there is still reason for concern In 2010 we did a pilot study 200 Questionnaires were distributed to practicing SLP professionals in New York and in Pennsylvania 71 (40%) were returned Respondents attended 39 different universities, collectively 20

21 Top two Courses with the least representation: In this year s pilot study, we asked Did you complete a course (required or elective) at the university level whose content focused exclusively on ASD as part of your terminal degree program? Note that 56% of SLP respondents graduated between 2000 and % 1. Autism 2. AAC 12% Step 2, continued Relative Limitations of SLPs Huge time & Scheduling challenges many children on case load rigid scheduling less contact with children Relatively less formal training in behavior management strategies e.g., FBA PBS 21

22 Strengths of ABA Professionals Expertise in instructional design Task analysis Defining behavior objectively Analysis of controlling variables (ABC) Individualized reinforcement systems Errorless teaching strategies Data-based decision-making Routine use of SSD to assess Rx effects Positive behavior support strategies Rich data base of autism Rx research ABAI supports Autism SIG Autism courses more often in curriculum Results of our survey 55% 45% Step 3, ABA Limitations Relative Limitations of ABA Professionals Limited broad-based knowledge about Linguistic components Developmental patterns Neurolinguistic challenges Higher-level language skills Extended discourse Speech production & disorders Range of AAC systems The range of evidence-based intervention options Limitation of BA A degree, license or certification in behavior analysis does not make you qualified to develop and oversee programs for individuals on the autism spectrum There needs to be a degree of knowledge on how to specifically apply ABA to the given population 22

23 Step 4 Leave Baggage at the Door Don t allow misconceptions to become barriers Don t equate person or personality with treatment or treatment ideas Step 4 Baggage Work together to help evaluate interventions Have an open mind and allow data to determine the facts Be open to the possibility that another perspective may have complementary value Step 5 Develop complementary collaborative relationships Honor principles of family-centered team-based orientation When determining treatment priorities, consider Severe comm. challenges of ASD Unique learning profile of child w/ ASD Evidence-based teaching strategies Family values Step 5, continued Share your expertise e.g., Communication processes Developmental patterns Speech production/disorders Extended discourse ABC analysis Behavior reduction strategies Verbal behavior analysis Instructional design SLP ABA 23

24 Step 5, continued Support ABA colleagues in your professional environment Focus on complementary roles Avoid negative characterizations of ABA treatments & philosophies Step 5, continued Attend the ABAI convention May, 2018 Join the SPABA SIG Join the Yahoo SLP-ABA Listserv Join the SPABA Facebook Group Encourage ASHA to invite ABA presentations Take an ABA professional to lunch Step 6: Support Your Commitment to Life-Long Learning Identify content areas you want to strengthen Autism? ABA? AAC? Family advocacy? Other? Step 6, continued If you re an SLP, add some ABA journals to your reading list e.g., Behavior Modification JABA JSLP-ABA recommend Vol. 5, No. 2 If you re an ABA professional, add some developmental journals to your list Journal of Child Language Brain and Language Developmental Psychology 24

25 Step 7 Advocate for greater transdisciplinary collaboration Support CEUs at annual conventions for SLPs at ABA convention for BA s at ASHA conferences Consider: Should ASHA offer a professional registration fee for non-slps? Invite ABA professionals to speak at conferences for SLPs; and visa versa Step 8 Advocate for individuals with autism and their families It s all about children and families Autism is a complex disorder Families feel the pressure of time They worry about their child s progress They want to know about treatment efficacy Professional affiliations don t matter Summary Collaboration is a skill. It must be taught and therefor should be included at the University level One of the key s to collaboration is accepting the fact that you can t possibly have all the answers or always be right Being in a band is always a compromise. Provided that the balance is good, what you lose in compromise, you gain by collaboration. ~ Mike Rutherford 25

26 Many ideas grow better when transplanted into another mind than the one where they sprang up. Thank You 26